Maternal and Infant Health Social Work Services OHCA Rules and Policies August 15, 2008

Who is OHCA?  Oklahoma Medicaid Agency – SoonerCare (Name of Insurance Program) – SoonerCare Traditional – SoonerCare Choice – Insure Oklahoma/OEPIC – Oklahoma Cares (BCC) – TEFRA – SoonerPlan (Family Planning) – Soon To Be Sooners

Member Eligibility  Two-prongs for eligibility –Low income individuals (based on federal poverty level percentages) –Categorical need (i.e., children, pregnant, disabled)  Eligibility determined by Oklahoma Department of Human Services (OKDHS)

SoonerCare and Perinatal Services  Large percent of births are paid by SoonerCare  FY 2007—SoonerCare paid for over 32,000 deliveries (57% of Oklahoma births)

Prenatal Care Benefits  Routine OB care—prenatal visits, labs, prescriptions, deliveries  Smoking cessation counseling  Prenatal assessment  Limited ultrasounds  High risk pregnancy services  Limited dental care  Genetic counseling  Lactation consultant services  Maternal and infant health social work services  Soon To Be Sooners

MIH Social Work Services  Direct face to face service provided to pregnant/postpartum SoonerCare members with psychosocial concerns that may impact pregnancy outcomes and/or the health of the infant--include but not limited to: –Domestic violence –Substance abuse –Lack of basic resources –Mental Illness

MIH Social Workers:  Connect women with necessary services which will promote optimal pregnancies and best outcomes for the infant –Help ascertain the best fit for the individual woman

MIH Social Workers:  Assist the woman in emotionally understanding and accepting the need for services or treatment –Ensure she follows through on all needed care –Follows up to see if the care she received met her needs

MIH Social Workers:  Provide short term problem focused counseling  Assess maternal emotional well being  Maternal –infant bonding and interactions

Eligible Providers  Licensed Clinical Social Workers (Licensed in the state services are provided)  Must have a current OHCA contract –Need to demonstrate current license –Six hours of continuing education or technical assistance in area of MIH

Coverage  Pregnant and/or up to 60 days postpartum SoonerCare &/or Soon To Be Sooners members  Existing psychosocial condition that may negatively impact the pregnancy/well-being of newborn  Condition identified by OB provider during prenatal care assessment or during Social work assessment

Coverage  Self referred or referred by any provider (no formal referral needed)  Services must be provided in office, home or other confidential clinic setting  Face to face and individual service  No separate reimbursement for inpatient services  Separate facility fee not reimbursed

Billing Codes/ Reimbursement Rates Use CPT codes:  Health and Behavior Assessment $16.79 per 15 minutes  Health and Behavior Intervention, Individual $15.41 per 15 minutes  Health and Behavior Intervention, Family with Patient Present $15.13 per 15 minutes

Maximum Units of Service  32 total units per pregnancy/postpartum (unit=15 minutes)  Maximum of 6 units per day/session  Any combination of the three codes as clinically appropriate  Billing time = time spent in face-to-face contact with the client

Contracting Information  Go to and choose: –Providers –Enrollment –New contracts –Maternal and Infant Health LCSWs  Download contract and follow instructions  Mail in completed contract with required professional documentation  Will take a couple of weeks to process/receive provider number  Call for help

OHCA Contract Requirements  Attach copy of certification  Show 6 hours of CEUs or technical assistance in MIH social work  Complete 6 hours CEU/technical assistance each calendar year  Maintain confidential records  Service records must be readily accessible for OHCA audit/inspection for 6 years from date of service

Getting started— Referral resources  Members may self-refer, no formal referral needed  Once contracted, obtain a list of contracted SoonerCare OB providers in your area  Outreach to OB providers, inform them you are a SoonerCare contracted provider and of your services  You may wish to discuss how you will share information regarding the patients  You should discuss how the OB provider will make referrals to you

Getting Started—Billing  Welcome packet from EDS (OHCA’s fiscal agent)  Field rep contact info  Free, on-site training or register for bi-monthly training in OKC or Muskogee –SoonerCare basics –Secure website –Training registration Training registrationTraining registration

Secure website  No cost (need internet access)  Verify member eligibility  Immediate notification of claim status –Denied claims resolution resources  Call center  Provider reps  Weekly payment cycle –If you file weekly, you get paid weekly

Third Party Liability  Third Party Liability (TPL) means another party is responsible for paying health care costs before (& sometimes after) SoonerCare pays  SoonerCare is the payer of last resort  About 10% of Sooner Care members have another insurer in addition to SoonerCare

TPL  Ask your clients if they have other insurance coverage  If so, get insurance carrier info from them  It is unlikely you will run into this situation, BUT if you do, help is available  Call OHCA--we will happily walk you through the process!  option 7 (TPL)

Documentation  Services must be documented in medical record to include: –Date of service –Start and stop time for each session –Service provider signature and credentials –Documentation of referral source

Documentation  Treatment plan including problems, goals and/or objectives  Methods to be used to address problems, goals and objectives  Progress made  Client response to the session/intervention  Any new problems, goals or objectives identified

OHCA Contacts  Child Health Unit –Terrie Fritz, LCSW, Director of Child Health  –Shelly Patterson, CPH, Perinatal Coordinator   OHCA Provider Representative – option 2  OHCA website –

Helpful OHCA Numbers  OHCA Call Tree (Provider)  OHCA Call Tree (Member)  SoonerCare Helpline (Member)  Behavioral Health  SoonerRide  Patient Advice Line

Questions?